Family interventions involving adolescents

By adolescence, many young people have achieved a degree of independence from their parents and are embedded in the culture of their peers, school, and/or community. The extent of adolescents' autonomy in today's world is such that there may be a temptation to consider addressing adolescent mental health problems in a different manner than those of younger children. However, among the interventions that have demonstrated the biggest impact for adolescents are those that focus on the youth in the context of his or her family. The only difference between these programmes and those discussed for younger children is that there is an increased emphasis on the broader social context of the youth—in addition to family, there is a focus on school and on peer relationships.

One type of family intervention for adolescents that is especially promising is multidimensional treatment foster care ( MTFC)/25 MTFC developed as an alternative to institutional treatment for young people with severe emotional and behavioural problems, including those involved with the juvenile justice system. It evolved for two primary reasons (see Chamberlain^ for a more comprehensive description of the evolution of the MTFC approach). First, it was found that there was often so much chaos and disorganization in the families of these young people that it was difficult to make treatment progress as long as they remained with their family. Second, although some progress could be made with a child placed in an institutional or residential treatment setting, this environment typically lacked ecological similarity with the home environment and it was therefore difficult to maintain treatment gains.

Within the MTFC intervention model, the youth is placed with foster parents who have received specialized training and who receive a high level of support and supervision from professional staff during the placement. The foster home environment has the potential to be quite restrictive if necessary, especially if the juvenile justice system is involved as a component of the treatment team. Removal from the foster home and temporary placement in detention or long-term institutional placement can be set up as consequences for illegal or antisocial behaviour. Thus, it is possible to exercise control equal to that in institutional settings, while at the same time allowing the youth to learn to manage his or her own behaviour in the community.

Moreover, just as the foster home can be quite restrictive, it also has a degree of flexibility not typical in group residential settings. As young people demonstrate increased or decreased ability to make positive decisions and associate with prosocial peers, the restrictiveness of the home can be incrementally adjusted accordingly. The MTFC approach includes the use of highly structured behaviour management programmes as a component of the treatment plan implemented in the foster home. This structure provides the youth with the opportunity to practise the skills that the foster parents are attempting to develop, while at the same time adjusting the youth's access to risky situations at a rate that matches the youth's progress in treatment.

While the youth is in foster care, his or her biological parents receive intensive behavioural parent training. This provides them with the tools to manage the youth's behaviour. In addition, family therapy involving the youth and his or her parents can be employed to help resolve past conflict and current problems. As the youth shows signs of progress in the foster home, he or she is allowed home visits. These provide parents with the opportunity to practise the parenting skills they have learned. The duration of these visits is gradually increased, until the child is ready to return home. An extensive 'aftercare' programme ensures that gains are maintained following reunification.

As mentioned, the MTFC approach also includes a focus on school in order to impact on the youth's academic performance and also to affect the youth's relationships with adults and peers in the school setting. In addition, control is exercised over the youth's behaviour in the community. Attention is devoted to both separating the youth from other troubled adolescents and helping the youth become more involved in prosocial activities.

The MTFC approach has been evaluated via a randomized control trial. The approach appears to have the effect of reducing recidivism, especially in comparison to group care.(2 28) Moreover, Chamberlain and Reid(25) reported that young people in the MTFC programme had a lower incidence of substance use and less contact with delinquent peers than young people in institutional settings.

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